Health Policy and Planning Advance Access originally published online on August 30, 2006
Health Policy and Planning 2006 21(6):432-443; doi:10.1093/heapol/czl024
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Risk factors for neonatal mortality in rural areas of Bangladesh served by a large NGO programme
1Centre for Health and Population Research (ICDDR,B), Dhaka, Bangladesh, 2Partners in Health and Development, Dhaka, Bangladesh and 3Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, Canada
Correspondence: Alex Mercer, c/o HSID, Centre for Health and Population Research, ICDDR,B, Mohakali, Dhaka 1000, Bangladesh. Tel: +880-2–8811751–60 (ext 2531), +880-2–9887928 (direct); Fax: +880-2–8823116, +880-2–8811568; E-mail: amercer{at}icddrb.org
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Abstract |
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Neonatal deaths account for about half of all deaths among children under 5 years of age in Bangladesh, making prevention a major priority. This paper reports on a study of neonatal deaths in 12 areas of Bangladesh served by a large NGO programme, which had high coverage of reproductive health outreach services and relatively low neonatal mortality in recent years. The study aimed to identify the main factors associated with neonatal mortality in these areas, with a view to developing appropriate strategies for prevention. A case-control design was adopted for collection of data from mothers whose children, born alive in 2003, died within 28 days postpartum (142 cases), or did not (617 controls). Crude and adjusted odds ratios (AOR) were calculated as estimates of relative risk for neonatal death, using ‘neighbourhood’ controls (241) and ‘non-neighbourhood’ controls (376). A similar proportion of case and control mothers had received NGO health education and maternal health services. The main risk factors for neonatal death among 122 singleton babies, based on the two sets of controls, were: complications during delivery [AOR, 2.6 (95% CI: 1.5–4.5) and 3.1 (95% CI: 1.8–5.3)], prematurity [AOR, 7.2 (95% CI: 3.6–14.4) and 8.3 (95% CI: 4.2–16.5)], care for a sick neonate from an unlicensed ‘traditional healer’ [AOR, 2.9 (95% CI 0.9–9.5 and 5.9 (95% CI: 1.3–26.3)], or care not sought at all [AOR, 23.3 (95% CI: 3.9–137.4)]. The strongest predictor of neonatal death was having a previous sibling not vaccinated against measles [AOR, 5.9 (95% CI: 2.2–15.5) and 12.0 (95% CI: 4.5–31.7)]. The findings of this study indicate the need for identification of babies at high risk and early postpartum interventions (40.2% of the deaths occurred within 24 hours of delivery). Relevant strategies include special counselling during pregnancy for mothers with risk characteristics, training birth attendants in resuscitation, immediate postnatal check-up in the home for high-risk babies identified at delivery, advice for mothers on appropriate care-seeking for sick babies, improving the capacity of sub-district hospitals for emergency obstetric and newborn care, and promotion of institutional deliveries.
Key Words: neonatal mortality, risk factors, NGO, maternal, newborn, child care, outreach, health services, care seeking
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Introduction |
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Globally, the neonatal mortality rate (NMR) is 36 per 1000 live births. Most of the 5 million deaths annually occur in developing countries, for which the NMR is 39 per 1000 compared with 7 per 1000 for more developed countries (Yu 2003
). In Bangladesh, the NMR declined in the early 1990s, but remained between 41–42 per 1000 in 1995–99 and 1999–2003 (NIPORT 2005). Neonatal mortality has been declining more slowly than post-neonatal or child (1–4 years) mortality, and it accounts for an increasing proportion of deaths among infants (63.1%) and children aged under 5 years (46.6%) (NIPORT 2005). Reducing neonatal mortality will be necessary for achievement of the targets set for child mortality reduction under the United Nations Millennium Development Goals (MDGs) (Haines and Cassels 2004).
There is evidence of a decline in neonatal mortality in recent years in rural areas of Bangladesh served by 27 non-governmental organizations (NGOs), based on data from the management information system (MIS). Checks on the recording of neonatal deaths in 12 of the NGO areas indicated that a recorded decline of about 50% since 1996, to below 30 per 1000, was probably genuine (Mercer et al. 2004, 2006). There are several potential explanations, including longer birth intervals, improved standards of living or nutrition, better healthcare seeking practices, or access to emergency care. However, high coverage of reproductive health outreach services has probably contributed to prevention of neonatal deaths. Of the married women who delivered in 2003 (all 27 areas), 73% had three antenatal care (ANC) check-ups from a qualified provider and 90% had two tetanus toxoid vaccinations, compared with 22% and 63%, respectively, in rural Bangladesh as a whole (NIPORT 2005).
NGOs have the potential to reach a large proportion of the population in Bangladesh to provide a broad range of preventive and curative services of high quality. The aim of this study was to identify the factors that are predictive of neonatal survival or death in areas that have relatively good coverage of reproductive health outreach services. Understanding these factors will provide a basis for development of strategies for improving neonatal survival.
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Methods |
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The NGO service delivery system
Twenty-seven local-level NGOs were contracted in 2000 under an open bidding process by a managing agency, the Bangladesh Population and Health Consortium (BPHC), funded by the UK Department for International Development (DFID).1 In the period 2001–05, the NGOs provided reproductive and child health outreach services to all households in rural areas allocated by the government's local health managers, which were spread throughout Bangladesh. BPHC provided technical support, and its manual for NGOs included recommendations from the World Health Organization (WHO) on essential newborn care (WHO 1996). NGO fieldworkers and paramedics gave advice and health education on most of the WHO topics, which included delivery cleanliness and cord care, thermal protection, early and exclusive breastfeeding, initiation of breathing and resuscitation, eye care, BCG vaccination, management of newborn illness, and care of pre-term and low birthweight babies. Apart from this, the NGOs had no special interventions for prevention of neonatal deaths, until four of them began preliminary activities under the Saving Newborn Lives Initiative (SNLI) in 2003, as partners of Save the Children (US).
Details of the development of the NGO services have been reported elsewhere (Mercer et al. 2004). Outreach services were based on female fieldworkers (family health visitors – FHVs) conducting visits every 1–2 months to about 7–800 allocated households each. The FHVs maintained registers of all married women of reproductive age (15–49 years), pregnancies, births and deaths among these women and children under 5 years. They provided basic health and family planning counselling, contraceptives (oral pills and condoms) and oral rehydration salts in the home; gave advice to pregnant women on the danger signs for delivery, neonatal sickness and when to seek help; promoted use of trained attendants at delivery; and motivated women to have ANC check-ups. Female paramedics conducted satellite clinics every month in different locations, providing family planning services, ANC, postnatal care (PNC) and basic curative care. Nine of the NGOs also had a static clinic at union-level (administrative unit: population 25 000), otherwise women and children were referred to the government sub-district hospital, the upazila health complex.
Study design
A case-control design was adopted for collection of data from mothers with a child born in 2003 who died (cases), or did not die (controls), in the first 28 days postpartum. Crude and adjusted odds ratios (exposure/non-exposure to various factors) were calculated as estimates of relative risk for neonatal death. In view of the difficulty of identifying separate care given to twins, the study focused on singleton births.
Study areas
The 12 selected NGOs were all those that had been providing health services in the same areas since at least 1996. They had continuous series of MIS data from that time, which were reviewed in a related study to assess the validity of the reported decline in neonatal mortality (Mercer et al. 2006). The study areas were located in 85 unions of 12 upazilas (sub-districts) spread throughout Bangladesh. Areas had been allocated to the NGOs by the government's local health managers, as hard-to-reach, and they had no government female fieldworkers. Although parts of the NGO areas could be reached off-road by cycle-rickshaw, visiting many of the households required walking several kilometres, crossing canals by bamboo pole and use of boats.
The NGOs aimed to provide services to all 105 000 households in these areas, which contained 96 642 registered married women of reproductive age (15–49 years) in 2003. Households had been classified by the NGOs in 1998: the ‘poorest’ reported annual per capita household expenditure of <Taka 5000 (<US$85), and these were 34.2% of the total in 2003. This was slightly higher than the proportion of households classified as ‘extremely poor’ (28%) in a national survey in 2000, on the basis of annual per capita expenditure <Taka 4877 (CIET 2001). This suggests the population was at least as poor as elsewhere in Bangladesh, and the majority would be considered poor by any international definition (e.g. income <US$1 per person per day).
Identification of mothers for interview
The research team visited each of the 12 NGO areas for 5–10 days between May–November 2004. Most FHVs had four registers as their households were usually divided into two areas, with registers for 2002–03 and 2003–04. All children registered as born alive in 2003 and died within 28 days postpartum were enrolled as cases, together with other neonatal deaths among this cohort identified by the researchers from other sources (e.g. verbal autopsy reports completed by the fieldwork supervisors in some NGO areas). All known cases were marked in the registers, and FHVs identified the two children born in 2003 who lived closest to a case, in the same village (neighbourhood controls). The mothers had the same FHV as the case mother and similar access to local health facilities. Two other children registered as born alive in 2003 were selected at random from the registers of other FHVs in the NGO's area (non-neighbourhood controls). Use of two sets of controls allowed for the possibility that quality and access to services might be different in different parts of an NGO area.
Data collection
A list of cases and controls was compiled and the respective FHVs accompanied interviewers to households. Structured interviews were conducted with case and control mothers to collect information on household economic circumstances; social and demographic characteristics of mothers; knowledge, practice and sources of advice on maternal and newborn care; use of reproductive and child health outreach services; maternity history; delivery experience; and neonatal sickness, care sought and source. Data were collected on immunization of the previous child and use of vitamin A, as indicators of child healthcare seeking practice.
Researchers also conducted interviews with NGO programme managers and health workers to collect information about the NGOs’ health services, and the advice given to mothers about maternal health, safe delivery and newborn care, on home visits, at ANC and in health education sessions. The government sub-district managers were asked about essential obstetric care (EOC) and neonatal care available at government facilities in the area, and what links the NGOs had with these services.
Data analysis
Data from the household survey of case and control mothers were entered into a database using Epi-Info (2000). SPSS was used to conduct bivariate analysis to identify factors significantly associated with neonatal death, and to calculate crude odds ratios as estimates of the relative risk for neonatal death. Adjusted odds ratios (AOR) were calculated using multiple logistic regression modelling, to control for socio-economic, demographic and other significant risk factors identified in bivariate analysis.
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Results |
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Among registered women in the 12 NGO areas, 11 253 live births were recorded in 2003, a general fertility rate of 116 per 1000 married women aged 15–49 years, compared with 122 per 1000 for rural Bangladesh in 2001–04 (NIPORT 2005
). After correcting for errors in recording, there were an estimated 210 neonatal deaths among children born in 2003 to 201 mothers (Mercer et al. 2006). Of the 184 mothers identified,2 42 were not available due to out-migration (20), death (6) or absence from the village (16). Interviews were obtained with 142 (70.6%) case mothers and with 241 neighbourhood controls for the 122 singleton babies (for three singleton cases, there was only one other child born in the same village in 2003). In addition, 376 non-neighbourhood control interviews were conducted. Socio-economic and demographic characteristics of mothers and households are shown in Table 1. The main factors significantly associated with neonatal death, based on both sets of controls, were mothers having no schooling, husbands having only primary schooling, low household expenditure and large household size. Non-neighbourhood control mothers were also significantly more likely than case mothers to be aged 20 years and over, to have a radio or TV, and to be Hindu, although most of the respondents (>90%) were Muslim.
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Maternal risk factors for neonatal death
Advice from NGO health workers
The NGO health workers were the main sources of advice on maternal and newborn care (Table 2). There was little difference between case and control mothers, except that few case mothers reported receiving advice at PNC check-up (many babies died before this). Generally, there was also close correspondence between case and control mothers with regard to the main advice they reported receiving. This included proper nutrition, avoiding heavy work, taking rest, tetanus toxoid vaccination, breastfeeding, keeping the baby clean and symptoms of common diseases.
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Use of reproductive health outreach services
Over 90% of case and control mothers reported that they had at least one ANC check-up (doctor or paramedic) prior to the delivery in 2003, most of them at an NGO clinic (Table 3). About two-thirds of both case and control mothers reported having at least three ANC check-ups, and about 90% had a second or booster tetanus toxoid vaccination. The small differences between case and control groups were not statistically significant based on 95% confidence intervals, with the exception of institutional deliveries, which included referrals for complications and were more common among case mothers.
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Coverage of married women (15–49 years) with family planning counselling was almost universal in the 12 NGO areas as a result of the household visits by the FHVs. Current use of modern methods was relatively high (54.5% of control mothers; 64.0% of all women), compared with rural Bangladesh as a whole (46.0%). It was also relatively high among control mothers aged under 20 years (57.0%) compared with Bangladesh as a whole (33.0%) (NIPORT 2005
). Maternity history
A higher proportion of case mothers than control mothers had more than five pregnancies, one or more previous stillbirths, and one or more previous child deaths, although the crude odds ratios were not significantly greater than one (Table 4). Relative risk for neonatal death was almost double for mothers who had two or more previous children dead or stillborn, although this was not significant after controlling for socio-economic, demographic and other significant risk factors from bivariate analysis: AOR, 1.8 (95% CI: 0.9–3.7) using neighbourhood controls, and 1.6 (95% CI: 0.8–3.2) using non-neighbourhood controls.
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Delivery experience and length of pregnancy
Only 22 (3.4%) of the 689 women who delivered at home had a qualified attendant (doctor, nurse, midwife or paramedic). Relative risk for neonatal death was lower, but not significantly (Table 4). A much higher proportion of case mothers than control mothers experienced at least one complication during delivery, which more than doubled the risk for neonatal death: AOR, 2.6 (95% CI: 1.5–4.5) using neighbourhood controls, and 3.1 (95% CI: 1.8–5.3) using non-neighbourhood controls.
Babies who died were significantly more likely to have been low birthweight, based on the mother's reported length of pregnancy (<8 months) and size of the baby (‘very small’). Although few control mothers (<1%) reported pregnancy <8 months, it was a highly significant risk factor for neonatal death after controlling for other factors: AOR, 6.7 (95% CI: 3.3–13.7) using neighbourhood controls, and 7.7 (95% CI: 3.8–15.3) using non-neighbourhood controls. Twin births were not included in regression models because of the difficulty of collecting separate data on the care for sick babies, but the NMR was 283 per 1000 live births, 17 times higher than for singleton births (16 per 1000).
Reported sickness among neonates
For sickness that mothers considered to be serious, the onset was much earlier among children who died (55.9% on the first day; 87.3% in the first 7 days), which was reflected in the day of death (40.2% in the first 24 hours; 72.1% in the first 7 days). Breathing difficulty was the problem most frequently reported by case mothers (47%) and control mothers (30–32%). Verbal autopsy reports were completed by some of the 27 NGOs (381 of the 662 reported neonatal deaths in 2003), which indicated that the main causes were birth asphyxia (38.6%), low birthweight (27.8%) and infectious diseases (14.7%), including acute respiratory infection (6.8%), jaundice (3.4%), diarrhoeal disease (1.6%), sepsis (1.6%) and tetanus (1.3%).
Care seeking and risk for neonatal death
About three-quarters of the case mothers reported that they knew what to do when the baby got sick and they considered it serious, compared with nearly all the control mothers (Table 5). The husband was the person most often mentioned as a decision-maker about seeking treatment for a seriously sick baby, although he was significantly less likely to be mentioned by case mothers.
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There were significant differences between case and control mothers with regard to sources of care for a baby considered to be seriously sick (Table 5). A significantly lower proportion (P < 0.05) of case mothers (30.5%) first consulted a qualified practitioner (doctor or paramedic), compared with control mothers from the same village (47.9%). Case mothers were also significantly less likely (P < 0.05) to have sought care from a homeopath or village doctor (usually unqualified), compared with both sets of control mothers. On the other hand, case mothers were significantly more likely (P < 0.05) to have consulted an unlicensed traditional healer (kabiraj) (21.2%). Estimated relative risk for neonatal death was high for those who sought care from a traditional healer rather than a qualified practitioner: AOR, 2.9 (95% CI: 0.9–9.5) using neighbourhood controls, and 5.9 (95% CI: 1.3–26.3) using non-neighbourhood controls.
Although nearly all control mothers (98–100%) sought care when their baby's sickness was considered serious, 35 (29.7%) case mothers did not. The relative risk associated with not seeking care was very high: AOR, 23.3 (95% CI: 3.9–137.4) using non-neighbourhood controls. However, most of these children died very soon after birth (21/35 first day; 29/35 first 3 days), and in many cases mothers reported having little time to seek care.
Vaccination of the previous child as a predictor of neonatal death
Child immunization coverage was very high in the study areas; only 4% of control mothers had not had their previous child vaccinated with BCG (Table 4). However, 53.1% of case mothers had not had their previous child vaccinated against measles, compared with 16.1% of neighbourhood controls and 8.7% of non-neighbourhood controls. This indicator was a strong predictor of neonatal death after controlling for socio-economic, demographic and other significant factors from bivariate analysis: AOR, 15.1 (95% CI: 3.5–65.4) using neighbourhood controls, and 32.3 (95% CI: 7.4–142.9) using non-neighbourhood controls.
Nearly all (16/17) of the case mothers who had not had their previous child vaccinated against measles had received ANC from a qualified provider before their delivery in 2003. However, relatively few (4/17) reported obtaining vitamin A for their children under 5 years in the last 6 months, whereas all those who had their previous child vaccinated against measles obtained vitamin A (P < 0.05).
Potential for preventing neonatal deaths through improved healthcare seeking practice
The NMR for children whose previous sibling was not vaccinated against measles was estimated at 54.1 per 1000, compared with 9.1 per 1000 for those with a vaccinated sibling.3 Based on the NMR for these two groups combined (14.5 per 1000), the population attributable risk was 0.436, and potentially up to 43% of neonatal deaths might be eliminated. Although many factors have probably contributed to the risk difference, special counselling for mothers whose previous child was not vaccinated (identified from fieldworkers’ registers during pregnancy) could help to improve healthcare seeking practice, particularly seeking qualified care for delivery complications and for a seriously sick baby.
The NMR among babies with sickness considered to be serious was 35.9 per 1000 when care was sought from a qualified practitioner, compared with 74.9 per 1000 when care was sought from a traditional healer or not at all.4 The population attributable risk was 0.331, based on the NMR of 53.7 for these three groups combined. Clearly, not all sickness considered to be serious would be life threatening, but up to 48 (33.1%) of an estimated 146 deaths among singleton babies with serious sickness in the 12 study areas might be prevented if care were sought from a qualified provider. It would require 841 mothers of seriously sick children to change their healthcare seeking behaviour (i.e. 18 to prevent one death).
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Discussion |
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Health education and maternal health care
A recent review and classification of neonatal mortality levels requiring different interventions suggested that an NMR of between 15–30 per 1000 live births is found in populations with a high proportion of deliveries assisted by skilled attendants, where the majority of births take place in health facilities, community health workers provide outreach services, or there are strong community-based support organizations (Knippenberg et al. 2005). The NMR of below 30 per 1000 among registered births in the NGO areas has been achieved without high coverage of qualified attendants, in areas where most deliveries are in the home, and sub-district government facilities are ill-equipped to deal with obstetric and neonatal emergencies. However, the NGO areas have a relatively high proportion of deliveries attended by trained traditional birth attendants (TBAs), regular home visits by fieldworkers, reliable satellite clinic sessions, and strong support from the community for their reproductive and child health outreach services.
As discussed elsewhere (Mercer et al. 2004), high coverage of outreach services compared with rural Bangladesh as a whole (Table 3) could have contributed to relatively low neonatal mortality in the NGO areas, and lack of access is no longer significantly associated with neonatal death. Health education for women is considered important for prevention, particularly advice on health and hygiene, avoidance of heavy labour, family planning, aseptic techniques, vaccination against tetanus, improved obstetric care and community support systems (Nicolau et al. 1989). Case mothers did not appear to have received less advice or information than control mothers, so the existing behaviour change communication is unlikely to contribute to further prevention of neonatal deaths in the NGO areas.
An earlier study in Matlab found that use of improved MCH services was associated with neonatal mortality decline, independently of social, economic and demographic factors (Bhuiya and Streatfield 1992). The reduction was due mainly to a reduction in tetanus deaths (Bhatia 1989), attributed to improved vaccination coverage among pregnant women through outreach services (Jamil et al. 1999). Coverage of both case and control mothers with tetanus toxoid vaccination was high in the 12 study areas, and lack of vaccination is no longer significantly associated with neonatal death. Similarly, most women had received at least one ANC check-up from an NGO paramedic prior to their delivery in 2003, although coverage in rural Bangladesh as a whole is low (50.9%) (NIPORT 2005). High coverage among case mothers (92.6%) indicated that there is little scope for increased coverage of ANC to have any further impact on neonatal mortality.
Neonatal deaths may also be prevented through use of modern contraception (Nasreen et al. 2003). In the 12 study areas, counselling of married women on family planning is likely to have been almost universal as a result of home visits by the NGO fieldworkers. Use of modern contraceptive methods was relatively high, compared with rural Bangladesh as a whole, even among women aged under 20 years, which could be particularly important for prevention of neonatal deaths as mortality is higher when mothers give birth at this age (NIPORT 2005).
Safer delivery
Many of the NGOs had trained TBAs integrated into the outreach service delivery system, and they were involved in reporting and follow-up of pregnant women. Other studies have found that training can significantly improve knowledge, attitude, practice and advice given by TBAs, and that training is associated with reduced perinatal mortality and deaths from asphyxia (Sibley and Sippe 2004). The trained TBAs interviewed in the current study were generally well-informed about safer home delivery, and about half of the women interviewed were attended by them. Although about one-third of deliveries were attended by an untrained TBA (dai), there was little difference in the proportion among case and control mothers, indicating that this was no longer associated with neonatal death in these NGO areas.
The proportion of mothers delivered in the home by a qualified midwife or nurse was very low, as in Bangladesh as a whole. However, a study of community-based maternity care in Matlab found little difference in the perinatal mortality rates between those who had been in contact with a midwife and those who had not (60.2 v 58.3 per 1000 births) (Kusiako et al. 2000). Most of the women in the NGO areas were delivered at home, and case mothers were significantly more likely to have experienced complications, after controlling for having a qualified attendant and other factors. Complication at delivery itself was found to be a major risk factor for perinatal death in the Matlab study. More than half the mothers diagnosed with obstructed labour or abnormal foetal position lost their babies during, or shortly after, delivery. The main conditions associated with very high perinatal mortality were biologic: eclampsia (323 per 1000 births), pre-eclampsia (152), breech presentation (375), prolonged labour (181), multiple pregnancy (215) and intrapartum haemorrhage (103). Women without any of these complications had a significantly lower perinatal mortality rate (48) (Kusiako et al. 2000).
Delay in seeking help for complications can be a common risk for perinatal death (Pattinson 2004). Although no data were collected on delay in the current study, it was found that about three-quarters of women who had experienced complications sought care. There was little difference between case and control mothers in the proportion seeking care from a qualified practitioner, suggesting that inappropriate care seeking for complications may not be a major risk for neonatal death compared with other risk factors. However, complications in themselves constituted a major risk for neonatal death. A total of 29 (27.4%) case mothers who delivered in the home, and 80 (13.7%) control mothers who did so, experienced some form of complication. The risk for neonatal death was 2–3 times higher for mothers delivering at home if they had complications (institutional delivery was biased towards case mothers due to referral for complications).
Sickness in the newborn and care seeking
Babies born premature (<8 months gestation) were significantly more likely to die, although only nine (7.4%) of the babies who died were reported by mothers to be premature. Almost all the babies who died had a sickness that the mothers recognized as serious, and the majority got sick in the first 7 days. The pattern of reported and recorded (verbal autopsy) morbidity was broadly consistent with the main causes of perinatal death globally (birth asphyxia, birth trauma, prematurity, sequelae of delivery complications and bacterial infections) (Gazi et al. 1999). An earlier study of births in 1992–93 in rural Bangladesh found that infectious diseases (septicaemia, meningitis, pneumonia and tetanus) accounted for more neonatal deaths (48.2%) than found in the current study (14.7%) (Chowdhury et al. 2005). However, the lower proportion in the 12 study areas is consistent with the decline in infectious causes underlying neonatal mortality decline in Matlab (Bhatia 1989; Alam and van Ginneken 1999).
The current study identified three main types of problem in seeking care for a sick baby: (1) inappropriate care seeking considering the symptoms observed; (2) delay in seeking qualified care; and (3) problems encountered when parents did seek qualified care. As these problems were not mutually exclusive, and the circumstances of individual cases were not always clear from interviews with family members, it was not possible to quantify the relative contribution of each.
Nearly all control mothers sought care from some kind of practitioner for a baby considered to be seriously sick, while significantly fewer case mothers sought care. An earlier study in Bangladesh found that the main reasons for not seeking care for sick neonates (born in 1996–98) were absence of supportive family members to do the housework and cultural restrictions on women's movement (Ahmed et al. 2001). On the other hand, interviews with mothers in the current study suggested that in many cases there was little time to seek care because of the rapid onset of symptoms and early death.
A national study of neonatal morbidity in Bangladesh found that mothers who had ANC were more likely to seek care for sick neonates from a qualified practitioner, although most families sought care from homeopaths (38%) and village doctors (37%) who are mostly unqualified (Ahmed et al. 2001). In the 12 study areas, there was much less use of such providers, and mothers were more likely to have sought care from a qualified practitioner, which was promoted by fieldworkers. However, seeking care from a traditional healer, or not at all, was a highly significant risk factor for neonatal death. Children of mothers who reported this were about four times more likely to have died than those for whom care was sought from a qualified provider. Although 23 of the 35 deaths occurred in the first 24 hours, and families may not have had time to seek appropriate care, the data suggest there may be scope for improving survival chances through early intervention and better access to trained healthcare providers.
Inappropriate care seeking for a sick baby appeared to be linked with superstition in some cases. Twenty-four case mothers said that ‘evil spirits’ were responsible for the sickness and death of their baby, and nine (37.5%) sought care from a traditional healer who cast spells, applied ‘spirit water’ and prescribed amulets. All 24 mothers had lost at least one previous child (some had lost two or three). On the other hand, another 23 case mothers who had lost at least one previous child did not mention ‘evil spirits’. Mothers attributing death to ‘evil spirits’, and others seeking care from a traditional healer, did not appear to be socially excluded or marginalized, as most had received at least one ANC check-up and tetanus vaccination at the NGO clinics. This contact with health service providers clearly presents opportunities for giving advice about symptoms and appropriate care seeking for a sick baby.
The symptom most frequently reported by mothers was breathing difficulty, and some had not recognized immediately that this was a serious problem. In other cases, access to a hospital was a problem, and the sub-district hospital (upazila health complex) was too far away (up to 20 km). Access was also affected by swollen rivers and flooded land, and lack of land transport. There was also a lack of resources at most sub-district hospitals for emergency neonatal and obstetric care. In some cases, when care had been sought for a sick baby locally, it was not available, and timely access at the district level was not possible. One example was a baby born after a complicated home delivery who was referred to the upazila health complex: the family complied, but there was no oxygen available and the baby died. Improvement of sub-district hospitals would need to include specialist medical staff and diagnostic capacity, as well as physical resources (Kalter et al. 1999).
Hospital data from Bangladesh indicate that the most common neonatal conditions leading to admission are birth asphyxia, low birthweight, birth trauma, seizures, septicaemia, jaundice and acute respiratory infection. The verbal autopsies available from some of the 27 NGO areas indicated a high proportion of deaths involving asphyxia and low birthweight, which can exacerbate the risk from asphyxia or hypothermia. Together with the data on very early deaths, this suggests a need for immediate post-delivery care for high-risk babies (premature, low birthweight, complicated delivery, multiple birth), from TBAs. As birth asphyxia is a common complication of prolonged and obstructed labour or prematurity, training for TBAs on resuscitation could be valuable. Trained TBAs could also report high-risk babies they identify at delivery to a paramedic, who could visit to provide a PNC check-up in the first 24 hours. This will be possible in some NGO areas, although it may not be feasible everywhere. Mothers also need to be given more instruction on recognition of potentially dangerous symptoms, on home-based newborn care and appropriate care seeking.
Home and community-based care
In view of the difficulties of resourcing hospital care and maintaining adequate facilities for managing neonatal and obstetric emergencies in a low-income country, there is considerable interest in developing home and community-based care for neonates, and research studies are in progress to develop strategies appropriate for rural Bangladesh.5 A package of home-based neonatal care introduced in rural India, including management of sepsis (septicaemia, meningitis, pneumonia), resulted in a reduction of 62% in neonatal mortality (62 to 25 per 1000) (Bang et al. 1999). Effective low-cost interventions, such as exclusive breastfeeding and thermal control of the newborn, can be promoted (Davanzo 2004). Although there is a lack of evidence about the effectiveness of specific interventions, newborn resuscitation and massage, and kangaroo mother care (skin-to-skin contact), may have important complementary roles. The latter, together with frequent and exclusive breastfeeding, and early discharge from hospital, has been proposed for low birthweight babies (Conde-Agudelo et al. 2003).
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Conclusions |
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The survey of case mothers and review of the MIS data for 2003 reported elsewhere (Mercer et al. 2006
) suggested that the NMR declined to below 30 per 1000 in the NGO areas. This could in part be due to good coverage of health education, family planning services, ANC, trained TBAs attending delivery, and fieldworkers promoting use of qualified care for sick babies. Despite the relatively low neonatal mortality, the current study found scope for further prevention of deaths through early home and community-based intervention. The fact that many babies (40.2%) died within 24 hours of delivery, sometimes with no recognized symptoms, indicates the need for early intervention for those at high risk. In areas that have already achieved good coverage of reproductive health outreach services, babies at high risk can be identified during pregnancy, so mothers can be given special counselling at ANC (those who lost previous children or did not have them vaccinated against measles). Others at high risk can be identified at delivery (complications, premature/small baby and multiple births). Counselling and health education for all mothers could improve knowledge about home-based newborn care, danger signs and the importance of seeking care for a sick baby from a qualified practitioner. Attendants at delivery may have a key role if trained in resuscitation, and through notifying paramedics about high-risk babies to be given an immediate PNC check-up in the home. This may be feasible in areas served by NGOs, although government services face severe constraints, including lack of motivation of fieldworkers and other health staff, poor supervision, unfilled posts and absenteeism. Increasing the number of institutional deliveries would also be a relevant strategy, together with improvement of the capacity of government sub-district hospitals to provide emergency obstetric and newborn care.
The system of service delivery in the NGO areas was basically that envisaged under the government's current sectoral programme for 2003–07 (home visits and satellite clinics). The 12 study areas were not intended to be representative of rural Bangladesh, but they provide evidence from widespread, and sometimes remote, parts of the country, that a well-supervised NGO programme can achieve high coverage of outreach health services. This reflects the regularity of home visits by fieldworkers, their efforts to promote use of services, reliable outreach clinics, good supervision, technical support from the managing agency and strong support from the community for the NGOs’ health activities. High coverage of reproductive health outreach services provides a basis for the introduction of interventions focused on prevention of neonatal deaths. Strategies for home and community-based newborn care being developed in Bangladesh can be applied and evaluated in NGO areas that have high coverage of outreach health services, to prospectively evaluate their effectiveness in such circumstances. In other developing countries where there is a strong NGO sector, and government lacks capacity to provide universal coverage of health services below sub-district level, these can be contracted out to NGOs through a managing agency. There is potential for scaled-up NGO service provision to make a significant impact on neonatal mortality.
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Alex Mercer is a health demographer. He worked on district-level health statistics and health surveys in the UK for several years. On completing an MPhil thesis on the epidemiological-demographic transition in 1986, he worked on relief health programmes in different countries, conducting health surveillance and surveys. Subsequently, as a Lecturer at the Centre for Development Studies in Swansea, UK, he advised DFID on NGO health projects in low-income countries, and joined DFID to manage its NGO health programme in Bangladesh from 1999–2002. He then joined ICDDR,B to work on health systems research and is currently Head of the Health Systems and Economics Unit.
Fariha Haseen, MBBS, MPH, is a medical graduate and worked as a Medical Officer in government service from 1995–2000. Following completion of a Masters degree in Public Health, she joined ICDDR,B as an Operations Researcher and worked on projects relating to adolescent reproductive health, community clinics and neonatal mortality. Currently she is working on three studies funded by GFATM: a national baseline HIV/AIDS survey among youth in Bangladesh, a rapid assessment of health services for youth, and a study of social, behavioural and biomedical risk factors among youth who are clients of sex workers (co-principal investigator).
Nafisa Lira Huq, BDS, MSc, originally qualified as a dental surgeon, and following completion of a Masters degree in nutrition, she worked on research on nutrition and reproductive health among adolescents at the Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies (BIRPERHT). From 1997–2002, she worked as a Research Coordinator on adolescent reproductive health with Concerned Women for Family Development (CWFD). Since then she has worked as an Operations Researcher at ICDDR,B, and is currently co-principal investigator on a study of community dynamics and sexual behaviour among rural youth in Bangladesh funded by GFATM.
Nowsher Uddin obtained a Master of Social Sciences (MSS) degree with honours in Sociology from the Dhaka University in 1978. Prior to joining ICDDR,B in 1998, he worked for Pathfinder International as a Program Officer, on design, development and implementation of NGO health and family planning service delivery. At ICDDR,B he has worked on operations research studies in support of the national Unified Management Information System (UMIS), and the system for municipalities. He is currently working as Project Coordinator on research into prevention of HIV/AIDS among youth, supported by the Global Fund for AIDS, Tuberculosis and Malaria (GFATM).
Mobarak Hossain Khan, MBBS, is a medical graduate and attended courses on reproductive health and research at the London School of Hygiene and Tropical Medicine; epidemiological methods at ICDDR,B; and health economics at University of Dhaka. In the past he worked for ICDDR,B as a Field Research Manager, planning and implementing operations research. He is currently a Technical Officer with Partners for Health in Development, having previously worked in this capacity with BPHC where he was responsible for quality assurance and collaboration on the ‘Saving Newborn Lives Initiative’.
Charles P Larson, MD, CM, FRCP(C), is Director of the Health Systems & Infectious Diseases Division of the Centre for Health & Population Research (ICDDR,B) in Dhaka, Bangladesh. Seconded from McGill University (Montreal, Canada), Dr Larson has been working at the Centre since 2002. He is a certified specialist in paediatrics and community medicine. His major field of interest is in health services and the scaling up of proven technologies that can improve child survival and reduce the occurrence of common childhood morbidities.
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The authors would like to acknowledge the considerable support and cooperation for this research from the staff of the 12 study NGOs: Assistance for Social Organisation and Development (ASOD), Centre for Development Services (CDS), Dwip Unnayan Sangstha (DUS), Jagorani Sangstha (JS), Resource Integration Centre (RIC), Souther Gonounnayan Samity (SGS), Society for Health Extension and Development (SHED), Shastha-o-Kalyan Sangstha (SKS), Shishu Niloy (SN), Unnayan Sangha (US), Unnayan Sahayak Sangstha (USS), Voluntary Organisation for Rural Development (VORD). We are grateful to the UK Department for International Development in Bangladesh who provided funding for the research.
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1Now Partners in Health and Development, an independent, not-for-profit organization.
2The number of stillbirths reclassified as neonatal deaths was an estimate based on a random sample of mothers of stillbirths in 2003. Of 109 mothers interviewed, 9 (8.3%) reported signs of life. Based on this proportion, it was estimated that 30 of the 354 stillbirths registered in the 12 areas in 2003 could have been neonatal deaths: the nine identified mothers were interviewed and 21 were not identified (Mercer et al. 2006).
3The corrected figure for neonatal deaths among 11 031 singleton births in 2003 was 180, an NMR of 16.3 per 1000 live births. Interviews were conducted with 122 (67.8%) of these case mothers. Assuming they were representative, the 122 deaths occurred among 7479 singleton births (11 031x0.678). Based on the proportion found in the survey, we would expect 2618 (35%) of these mothers to have a previous child aged under 5 years who had not died. Based on the coverage in the 12 study areas, 2304 (88%) would have been vaccinated against measles, and 314 would not. There were 21 neonatal deaths among babies with their previous sibling vaccinated, and 17 among those with their previous sibling not vaccinated: NMRs of 9.1 and 54.1 per 1000, respectively, and 14.5 per 1000 for the two groups combined.
4As in footnote 3, it was assumed that the 122 deaths occurred among 7458 singleton births in 2003. Based on the survey proportion, we would expect 2814 (37.6%) of the mothers to have babies who had sickness in the first 28 days that was considered serious. Again, based on the survey proportions, we would expect 1002 (35.6%) of these mothers to have sought care from a qualified provider, and 841 (29.9%) to have sought care from a traditional healer or not all. There were 36 and 63 neonatal deaths, respectively, among the children of these two groups of women: NMRs of 35.9 per 1000 and 74.9 per 1000, respectively; and 53.7 per 1000 for the three groups combined.
5A study of Community-based Interventions to Reduce Neonatal Mortality in Bangladesh (Projahnmo) is being conducted by ICDDR,B Centre for Health and Population Research in Sylhet Division, in collaboration with NGOs and other partners. The study aims to evaluate the impact of a package of obstetric and neonatal care practices, including management of serious neonatal infections by first-line health workers, and to improve practices, including management of serious neonatal infections by first-line health workers, and to improve newborn care and the recognition of serious infections in neonates by mothers and trained first-line workers.
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